Dr. Boland outlines the risk factors of COVID and IBD and encourages the vaccine without interrupting treatment.
unfortunately you have dr Brigitte building. My colleague at UC SAn Diego to talk about covid 19 and I. B. D. Uh in the post vaccination. World President please take over. Thank you said. Um So it's my pleasure to talk and give a little bit of an update on Covid and IBD. Uh My goal is to really touch on a bunch of you know basically the main questions your patients, I'm sure asking you every day you're my disclosures. So briefly I'm going to talk mostly about Covid and IBD. The risk of getting covid if you're an IBD patients and then the risk factors for severe covid and then go into co vaccination and IBD. So um you know, brief update of what we what we've learned so far. So the first question I think that everyone is getting asked by their patients over the past year or so or more is really our patients with IBD at higher risk for getting covid. Um And I'd say the overwhelming results that we've determined from many different studies um with each of their limitations is there's really no significant risk um or no significant difference in the incidence of Covid and IBD versus the general population. I mean we've we've learned this through multiple different IBD cohorts because of the nature of Covid. We don't have perfect studies but you know we have emerging data from US data from a large via cohort. Um Again it's from the v. A. So mostly men some limitations there. Also gotten data out of Italy and France where they also did not see higher rates and we're not seeing higher rates of severe covid. Um In asia got some information from cohorts, they're saying no significant increase in the risk of IBD um Covid cases and then also some new york city case controls, case controlled studies where they saw really even less death and I see you and admissions and diabetes patients um to go into a couple of the specific studies. Um one specific cohort study from new york city where they looked at a cohort of IBD patients. So no risk, no differences in the rates of Covid but identified that active active disease appeared to be a potential risk factor. Um What they saw was in preparing patients with active disease versus inactive disease and they measured this in multiple different ways. We get clinical scores and dystopic scores crp being elevated um an elevated fecal cal protected and saw a very consistent relationship and basically active disease being associated with rates of covid. So certainly uh you know an interesting concept and it's kind of emerged from a couple of different studies um in a very large retrospective via cohort um looking at 30,000 IBD patients um they saw that being on steroids seem to be associated with a higher risk of covid and also a risk for severe covid. Um It's just a Kaplan meier curves showing that the patients on corticosteroids were more likely to get Covid or have covid next. Um You know I think the next huge question that we all get asked is about whether covid outcomes are worse. So if I have, if I have IBD, am I going to have severe covid? Um, and the first I think piece of data we really got was the early experience from the initial secure IBD registry. And what this is is it's a registry where providers register their patient cases. So there's significant bias in this and I think it's important to consider, but it was really the first way that we were able to collect the data on what happens to IBD patients who get covid. Um, and what clearly emerged was sort of the same thing we saw in the general population that really comorbidities and age were really associate with worse outcomes. The things that were then found to be unique to IBD patients really were the corticosteroids during use and potentially active IBD were associated with worse outcomes. Um, you know, I think active disease, particularly this setting is a little bit confounded by the use of steroids. But certainly these were the things that emerged from the early secure IBD data later on. You know, the kind of subsequent publications we've seen in terms of covid outcomes and IBD have you know, I think created some some question about these outcomes and I be in IBD patients. So the next cut of data from secure IBD where they had more IBD covid cases showed a questionable increase in the rate. Well they showed an increase in the rate of severe covid in patients on combination therapy with with TNF inhibitors as well as in patients on thigh appearance and particularly as compared to people on TNF inhibitor monotherapy. Um They did not see the same differences between different using different biologics like kidnap and that Eliza mob. So I think this raised some questions. Um as I mentioned before this is really physician reported outcomes. So there's a real bias here and I think you know our concerns about these medications really informed some of what we're actually reporting. So significant potential bias and then founders but probably has led to you know some patient questions. Um But then I think you know looking at other data and sort of the sum of everything we know including this french national health database really aren't seeing um you know not only not seeing more severe covid in these patients but also not seeing this difference between combination therapy. Um And I open hearings as compared to monotherapy. So I think um you know the overall overall message is that we don't think there's a worst risk of severe covid with my appearance and combination therapy. So just to summarize that first part um and not to hammer home thinks too much um there's really no significant increase in the risk of covid that we've seen so far in I. V. D. Um steroids and maybe active disease seems to be a significant risk factor for potentially getting covid. And then in terms of covid severity um it's really steroids, age comorbidities sort of the usual things. And potentially active disease may increase that risk. Um So other than steroids we don't think that you know the typical IBD medications biologics as well as by appearance. They don't really seem to worsen covid outcomes and there's even some discussion about the potential beneficial effects. Um Some of the Jak inhibitors have been actually looked at for for covid. Um So I think that really underscores the approach to Covid. Really try to stay on your medications control inflammation to reduce your risks. So then shifting a little bit towards covid vaccinations and IBD. Um not to hammer home what everyone knows but the main vaccination I'll focus on the M. RNA covid vaccines that are the two dough series. Much less is known at this point about the single dose vaccinations. Um And specifically for IBD these you know may have some some specific concerns um with regards to safety as a quick reminder this is not a live vaccine. Um And overall you know while they're kind of case reports of people flaring after the vaccine I think it's important to kind of go over the safety which I'll discuss a little bit more but this does seem to be safe in our patients. Um And overall appears to be effective and there is some indication that two doses and now maybe three maybe particularly helpful this population. And um and stories of the thing, I think that it's most clearly emerged as being thought to reduce efficacy. Although I think actually less sites have been on, been done on that mostly because it's sort of a known risk factor from other vaccines. Um so really a common question that we're just starting to get data on is sort of how do people react to this vaccine? A lot of people obviously, you know, a lot of people have gotten this vaccine. No, people tend to feel lousy more lousy after for the second dose. Um So I think the question that I get all the time for my patients is you know, am I going to feel worse because I've IBD after getting the vaccine. Um So some work out of a consortium run out of cedar Sinai started to look at this and sort of compare how patients on biologics with IBD versus patients, not on biologics did with sort of their reactions to the vaccine. Um here are some slides. So in purple, are the patients not on biologics and in green are the patients on biologics and comparing dose one dose too. So, you know what we already know is that symptoms are generally worse after the second dose. This is very consistent with the clinical trials and what most people experience what's probably a little unique to the IBD patients. Um and here is sort of a list of the different really common side effects like injection site reactions, fatigue, headache, dizziness, fevers or chills, um and memory or mood changes. Um, but what they actually saw is that patients on on biologics in green had less frequent symptoms, particularly after the second dose. They saw less injection site reactions, less fatigue and malaise and less fever and chills. And actually saw a shorter duration in those two. So kind of an interesting thing to, you know, to relate to patients, particularly when there's a lot of vaccine hesitancy in a population where we think it's really important to get vaccinated. Um the question that you got sort of that has also emerged is probably one of the most common questions we're getting is are the covid vaccines effective and IBD patients. And really this mostly relates to the effect of the medications that we're using. The biologics are used to control the disease. Um, Once they emerged, that led to some questions about this was a study out of the UK that showed that inflicts a map may reduce zero conversion or the ability to mount a sufficient antibody response that kind of gets to sufficient typewriters. Um really after one dose, there was lower zero conversion and patients with IBD. What they found though is that after two doses or the equivalent of a covid infection. Plus the vaccine is relatively similar. Syria conversion rates. Um, So here's actual data when you look at basically the blue purple line here indicates the threshold for syria conversion. Um And so they see, you know, pretty good rates of syria conversion after the first dose and second notes. But just tend to be a little bit higher with the vandalism treated patients. And probably what's most important is looking at the number of people kind of stuck below that line. Um So there's a couple more with the inflicts a mob therapy. Um And then they looked at kind of the proportion of patients who actually c zero converted after two doses. Um And saw you know basically the best responses were in the middle is about mono therapy a little bit less and less. A mob plus thio pairings a little bit lower. And inflicts about mono therapy and the lowest in inflict some combination therapy. And then, you know, more studies have emerged since this initial study came out and I think the general um overwhelming theme has been that we're not actually seeing that much differences in sierra conversion rates and patients on biologics and thigh appearance as compared to those not on on those medications. Um There's this cedar Sinai cohorts I mentioned that focused mostly on adverse events from the vaccine. Saw them less likely in IBD as I described. Saw slightly lower typewriters in patients on biologics but not not significantly. So um a cohort out of UNc showed very similar antibiotic writers and people on different beauty treatments and didn't see any IBD specific treatment affects other than steroids which seemed to lower tigers. And then a smaller cohort from Mount Sinai. They didn't see any differences in tigers and IBD patients versus healthy controls. Kind of regardless of therapy type. So just to summarize the current recommendations, we are recommending vaccination for our patients. We are not stopping therapies for vaccination. There is a little of that going on in some other arenas. I think rheumatologist have some some kind of some adjustments they may be making, which we have not suggested. Um And systemic steroids do seem like the thing that most consistently will reduce efficacy of covid vaccination. So those would be something very reasonable to try to reduce if you can before someone gets back, it's needed to optimize on the vaccine response. Um and then recently the CDC came out with guidelines on recommendations for the covid third dose for patients on immune suppressing medications and really something that emerged primarily out of transplant data. Um and they do say that basically patients on almost all of our therapies are quote unquote eligible for a third dose and this is the idea behind the third dose is really boosting up tight ear's because some concern about lagging response to the initial two doses um kind of separating it from a booster. Um and so basically all patients on TNF inhibitors. Anti immigrant anti I'll 12 20 threes and then modulators and corticosteroids are in this category of people eligible. Um They don't specifically comment on small molecules like Jak inhibitors or um Ozan Ahmad but um are my general proteins has been to treat those people in a very similar manner. Um and as I mentioned, you know, I think it's very likely sort of all of us will be in this category of getting a third dose which is seen more I think in general population as a as a third dose booster kind of for immunity waning over time. So um you know, just to reiterate IBD patients don't seem to be at higher risk for covid. Um the risk factors for severe covid are very similar to the populate the general population other than steroids and I think it is really key to try to control disease with steroid sparing recommend treatments as best we are able. Um we're now entering a new era where patients hopefully have been vaccinated and I think less is known about kind of the risk of these newer variants and um any specific effects um and risks after, you know, the first two or three vaccinations. So we do recommend vaccine. Our patients without interrupting therapy. Um Our patients basically almost all of them on any sort of immune modulator biologic are eligible for a third dose. I think most importantly it's really important to talk to your patients about the vaccine. I think you'll find if you talk if you talk to everyone there are people who still holding out, you know. Um, and I think taking that extra moment is really helpful for, uh, you know, convincing people that it's worth it.